A POPULATION HEALTH APPROACH TO MEN S HEALTH John J Macdonald Fourth National Men s and Boys Health Conference, September 2001, University of Western Sydney, Richmond, NSW ABSTRACT The welcoming address to the conference, that celebrates the numerous masculinities that men portray, and acknowledges the contribution of the indigenous male health convention that immediately preceded the conference. Welcome to the Men s Health Conference Building on the good work of other conferences and on the contributions to boys and men s health on the part of many people, I want to offer some few words of orientation. This conference sets out to celebrate all men. We know from research what common sense teaches us: social inclusion is good for your health. Social exclusion is bad for it. This conference - if it succeeds at all will contribute to a sense of belonging, of pride, of social inclusion, for all men who will be here these days. Women who work for men s health and there are many, are of course, honoured and welcome too. But the focus is on men s health and ALL men s health: perhaps especially, all marginalised men: men in prisons, men separated from their children, men out of work. We are about all men: older men, younger men, boys, men of all sexual preferences, Indigenous/ Aboriginal men and men from diverse cultural backgrounds. We, of course, recognise and celebrate this diversity there are many masculinities, as some would say. But we celebrate also what we have in common, the fact that we are men. I shall have more to say of that shortly, the topicality of celebration of the fact that not only is it just OK to be a man, it s good to be a man. A healthy society is one which gives a sense of inclusion to its populations we can think of celebrating children, older people. We can also think of men: a healthy society is one which nourishes men. Before I leave the issue of diversity and one-ness, I need to say something about Indigenous men. In all men s conferences they would have a place. This week this campus of the University of Western Sydney has witnessed the National Indigenous Men s Health Convention. I say with all sincerity: there is a special link with Indigenous men in this national Conference. We are committed to learning with and from Indigenous men. This is not just fanciful: one example: from Indigenous men we have found a way to talk men s business, to deal with issues around boys and men s wellbeing in ways which respect women and women s business but which start from a positive position, not a negative one about men. This is liberating for our 1
culture, as I will say. It also allows us in Australia to give the lead to European and North America cultures rather than simply following them, as too often in the past. Seeing boys and men in a different way There is need for a re-examination of the way boys and men s health issues are conceptualised and dealt with in our society and in the services which most closely impact on their wellbeing, notably education and health services. Ideology and even stereotypes, rather than rational and equitable approaches to population health have often shaped attitudes, policies and practices around men s health. In particular, the pathologising way of seeing men and boys which is supported by much Men s Health Policy does little to build men s health. It is time to move away from a blaming way of seeing men s health principally in terms of men behaving badly. We need to move towards a genuine population health approach which builds on boys and men s strengths and their social inclusion, whatever their age, sexual preference, ethnicity, while embracing such contradictions as may emerge from this approach. Our work should contribute to a cultural shift in positive thinking about boys and men amongst Health and associated professions like Education, as well as in general popular culture. Our task must be to build health strengthening environments for boys and men. When we think of population health strategies, there is a logical division into subgroups: older people, women, children, Aboriginal and Torres Strait Islanders. But men? Many health practitioners and health policy makers in New South Wales would subscribe to a Population Health Approach. Some of the characteristics of this approach would be:! A social view of health, including the biological, but encompassing consideration of the social determinants of health (Marmot and Wilkinson 1998, 2000)! A conceptualisation of health and health services which combines a balance between prevention and treatment, with an emphasis on health and its maintenance and not just on disease and its treatment! The incorporation of the elements of WHO s Health for All perspectives, notably a concern of equity, for participation of the given population and acknowledgement of the role of other sectors in creating sustainable environments of health! A concern for evidence-based policies and programs.! The situation of health of individuals and communities in a historical, political economic context. Salutogenic I would add also that a population health approach has the potential to adopt a salutogenicperspective, rather than the pathogenic and pathologising approach we have inherited from western medicine s preoccupation with disease. Population health listens to people s views and builds on their strengths. 2
Antonovosky coined the phrase, salutogenesis, in the context of human resilience. I use the expression also, in counterdistinction to pathogensis, to convey the need to move away from the pathology-oriented, deficiency and disease-based model of medicine. We need a population health approach to boys and men s health, to focus on what creates health, not just what puts us at risk of disease. This would be a sea change for health services. Medicine is focused on disease and pathologies; in the case of men there is combined with the already mentioned concern about man behaving badly : the social pathologies of men. As I have said, what we need is a population health approach to men s health: a rational view of men s health which sees health in its social economic, historical cultural context. Do we have a population, salutogenic approach to men s health? We do not. I offer you the (Australian) Doctor s Reform Society Men s Health Policy as an example of our culture s pathologising view boys and men: 8.3 Men's Health 8.3.1 The DRS recognises that there are particular issues for men which affect their health. These issues can arise from the process of socialisation to compete and dominate in social and political spheres which can foster violence. As a result of this, many men experience a number of psychological difficulties, a reluctance to acknowledge and address their own health issues and diffidence in approaching health services. (see also 15. Violence and Aggression) 8.3.2 The DRS recognises that despite the fact that the majority of health research has been conducted on men and that there are biases towards men in health care teaching (due to the dominance of men in teaching and research positions), men still have poorer health in a number of areas and a lower life expectancy than women. 8.3.3 The DRS believes that increased attention to lifestyle changes (such as exercise, reduction of alcohol consumption, and strategies to reduce violence) are more important in improving the health of men than technological improvements in health care. 8.3.4 The DRS believes all men in Australia must have access to appropriate information and education about health. In particular, men need to be encouraged to make earlier, more appropriate use of primary health services. 8.3.5 The DRS encourages the development of accessible, appropriate services for those who are victims of violence. It is also important to develop preventive and treatment services for those who are at risk of, or have, perpetrated violence. (see also Violence and Aggression 15.1.3 General, 15.3 Domestic Violence and 15.4 Sexual Assault) 8.3.6 The DRS believes in order to improve men's health, the men's health movement needs to focus on the above issues, rather than competing with the women's health movement. A population, salutogenic health approach to men s health? Far from it. What we have here is a pathologising perspective on men: men as violent. Any suggestion of a population health approach to men: some means of assessing their needs and strengths? Men and the social determinants of their health? No way: the focus is 3
exclusively on men behaving badly, men taking risks, men failing the health services by not attending rather than any examinbation of the health services perhaps failing men. In the work I did to prepare for this conference, I began an overview of the international literature on men s health. I will continue with this work after the conference. What I present here is only a snapshot but I suspect that in the Anglo Saxon literature I am reaching saturation point, by which I mean there will probably be no surprises when I add more to my sample. The topics dealt with in the literature in men s health have to do with: biological health, specifically heart and prostrate men s behaviour (bad) men s use or non-use of services theoretical understanding of men s health, generally feminist theory There is also some emerging work on the social determinants of health, particularly employment and health. There is much to do. At Public Health and Health Promotion Conferences there is no place for men s health. At a recent Men and Relationships conference: over 50% of the papers on men and violence: men as lovers, as fathers, as citizens, as sons? No, the research focus and resources are on the social pathologies. Some of us would define health as the capacity to move through the world positively, dealing with the negative in what is encountered and being nourished by the positive: this is closer to what Antonovosky meant by salutogenic: the capacity to embrace the whole situation and grow with it. I enlarge the idea to include salutogenic environments: contexts which positively foster the total health of boys and men. I am suggesting we need a salutogenic view of boys and men, part of a population health approach: seeing us in our historical, social and economic context. Does this mean ignoring any shadows, like violence? Not at all. It means having the courage to integrate all into a bigger picture. The phenomenon of violence has to be seen as part of a bigger picture or we will get nowhere. And it cannot be the starting point for policies on men s health like it is for our good friends, the Doctors Reform Society. I was looking for the airport in a Celtic country. I was late and it must have shown on my face as I asked the farmer in his field the way to the airport. If I were you and going to the airport, I would not start from here. He said. If we are to build a national culture and a health culture that nourishes young men, old men, indigenous men, all men, we must not start from the position of violence. A salutogenic view of men embraces the contradictions but looks for a balanced view of men s and boys behaviour. It builds on what is good for and by boys and men. In a sense, that is what MHIRC sets out to do and what we invite you to do in the conference: to celebrate boys and men, in their fullness. To embrace the diversity of men and boys, acknowledge our weaknesses and celebrate our strengths. Celebrate the achievements and contributions of millions of men; their labour, their endurance, 4
their commitment to support the ones they love. Before we blame, do the population health and rational thing: ask WHY?. Look for causes and not just symptoms: good therapeutical practice. A population approach to men s health is what is called for: men s health is a public health issue of considerable topicality and is attracting a deal of attention internationally. This emerging interest is reflected in New South Wales and in Australia as a whole. It is sometimes said that we follow where other countries lead, notably the USA and the UK. In the matter of men s health, however, NSW is, at least in direction and intent is moving towards a rational population health approach. Moving Forward in Men s Health, the paper on men s health published in June 1999 leads the way in Australia. We build on that and The NSW Department of Health has funded the Men s Health Information and Resource Centre (MHIRC); this is the team which is glad to welcome you to this conference. We embrace a population view of boys and men s health, one which incorporates a salutogenic view of boys and men s health. The conference should help us all move forward positively, as individuals, as people working with men, as a country. In Conclusion Before I finish, I want to share with you a roll of honour: I honour the good in all men I honour all the good men have done and do I honour all the men of this country, Indigenous men, elders and the men of the future. Where they allow us, let us talk a talk with them and walk our walk with them I honour all the men who have taken their own lives I honour all the men who suffer the separation from their children I honour all the men who take risks for us, who risk their lives for us I honour all the men who struggle for a more just society In Australia I honour all the men who have worked for men s health. We, no less than they, are historical beings and because they defined themselves in particular historical and social settings, often feminised settings, their talk was of its time. Our talk is of a new time. They started where they were and we build on what they have done. I honour all the women who have contributed in families and relationships and in the professions to the wellbeing of boys and men I honour the Men s Health and Wellbeing Organisation of Australia I honour Michael Kakakios, from the Department of Health NSW who is our brother and sponsor and his former colleague, Andrew Gow I honour all of you here, from our indigenous elders to our keynote speakers, notably Richard Fletcher. I salute the outstanding contribution he has made to the wellbeing of men of the future 5
I honour the work you all do for boys and men I honour my colleagues in MHIRC who have worked so resiliently to make this day happen: Micheal Woods whose brainchild all this is; Gillian Sliwka who has shown that women can and do support positive health in boys and men; Dennis Mcdermott, Anthony Brown, labouring away without the limelight, Richard Aldrige who convened the Indigenous Men s Health Convention, Abdul Monaem, Phil Emery, valiant volunteer, our national teleconference colleagues, some of whom are present here, and all mentioned in the program; our local advisory Committee, again, some of whom are present here: Marie-Anne Maakrun, Michael Keats, Mohammed Mahat, Steve Carrol, Peter Llewlyn Smith, Carmine de Campli. John J Macdonald Professor of Primary Health Care, Director, Men s Health Information and Resource Centre, University of Western Sydney, Hawkesbury. 6